https://leader.pubs.asha.org/article.aspx?articleid=2683706Lost in the PresentThe aftermath of brain injury can be complex and unpredictable, as seen in a teenage patient’s unusual type of memory loss.2018-06-01T00:00:00FeaturesChristopher Stevens, MS, CCC-SLP

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Features | June 01, 2018

Lost in the PresentThe aftermath of brain injury can be complex and unpredictable, as seen in a teenage patient’s unusual type of memory loss.

Christopher Stevens, MS, CCC-SLP, is a clinician in the Concussion Clinic at Lucile Packard Children’s Hospital in Stanford, California. He is an affiliate of ASHA Special Interest Groups 2, Neurogenic Communication Disorders; and 13, Swallowing and Swallowing Disorders (Dysphagia). klaxonner@hotmail.com

Christopher Stevens, MS, CCC-SLP, is a clinician in the Concussion Clinic at Lucile Packard Children’s Hospital in Stanford, California. He is an affiliate of ASHA Special Interest Groups 2, Neurogenic Communication Disorders; and 13, Swallowing and Swallowing Disorders (Dysphagia). klaxonner@hotmail.com×

Stevens, C. (2018). Lost in the PresentThe aftermath of brain injury can be complex and unpredictable, as seen in a teenage patient’s unusual type of memory loss.. The ASHA Leader, 23(6), 52-59. doi: 10.1044/leader.FTR2.23062018.52.

After a concussion, every patient recovers at a different pace and experiences a different set of symptoms, some of them affecting communication, memory and concentration skills. Fortunately, most recover within days to weeks.

In some patients, however, the recovery from a mild traumatic brain injury (TBI)—a form of mild TBI that typically results from a blow to the head or neck—can be atypical or prolonged. In these cases, a more specialized approach, such as through treatment at a concussion clinic, may help improve function and support recovery.

I work with children and adolescents at such a clinic, and through this work, I have learned to adjust my treatment of their memory, attention, processing speed and verbal fluency to fit each unique case.

I also work closely with the student’s medical team, school (see “Supporting ‘Return to Learn’ After TBI”) and family on their road to recovery. Given the diversity of cases we see when assessing and treating TBI-related cognitive-communication impairments, I thought it would be useful to share what I learned from one student’s unusual concussion recovery.

Maggie couldn’t remember the layout of her family’s summer cabin—or what she had learned in her sophomore Spanish class.

A different kind of memory problem

Maggie,* a vibrant 15-year-old, came to us after her third concussion, which happened during a tubing accident while on a family vacation in the summer of 2017. When we met before she began her junior year of high school, something struck me: Her complaints differed markedly from what I usually hear. Typically, a student may complain of feeling “foggy” and being “forgetful.” New learning is generally more taxing on their brain, and it’s fairly typical for them to struggle with short-term recall or thinking quickly.

Maggie, however, was experiencing only mild fogginess. Her main concern? She couldn’t remember her grandmother’s name. She also couldn’t remember the layout of her family’s summer cabin—or what sh e had learned in her sophomore Spanish class. She couldn’t even recall her 14th birthday party or the names of many of her longtime friends.

This symptom hinted at a larger problem with long-term memory: Maggie struggled most with episodic memories (events) and name recall, from her early childhood up to the spring before her concussion. I have spent numerous hours educating, teaching and implementing techniques to support short-term memory impairment. How was I going to help in Maggie’s case?

When I sat down with Maggie and her mother at her first appointment, we discussed goals for treatment based on my assessments and what she wanted to improve. In our clinic, I typically administer subtests from standardized assessments, looking at immediate recall and working memory for numbers and sentences, processing speed, and verbal fluency. I also administer informal assessments looking at short-term recall of unrelated words, divided attention and prospective memory (remembering to complete a task in the future).

Fortunately, the assessments had revealed some good news: Maggie’s short-term recall and working memory were quite intact. If I provided her with new information, she could access it the next time she needed it (people’s names were an area where she needed the most reminders).

Maggie struggled most with episodic memories (events) and name recall, from her early childhood up to the spring before her concussion.

Memory workarounds

Maggie and I focused her treatment on strategies for managing the mental blanks she faced when trying to access pre-concussion information. (I discussed the case with a neuropsychologist colleague, and she had treated a similar case in a similar way.) I would pose a question related to her past, such as, “What was the name of your elementary school?” And we would come up with the strategy for accessing the information, such as using Internet searches to pull up a list of local elementary schools. Maggie was then able to recognize the correct name.

Other strategies included using her friends as compensatory supports if she could not remember someone’s name at school or using map applications to find a store whose location she’d forgotten.

I had Maggie start the process of remembering and see where we could fill in the gaps. For example, if she was trying to remember a movie she’d seen, I’d urge her to think of general categories, such as “the type of movies I typically watched with my friends.” This was far better than simply saying, “I can’t remember.”

We also took a proactive approach to researching a place or topic before she needed the information to capitalize on her strengths in learning and retaining new memories. For example, Maggie worried about being unable to find her classes the first day of school. To address this, we printed out a map of her school and circled the location of her classes. She did a practice walk with her mother and counselor, so she could be prepared. I also suggested looking at old textbooks and notes from her sophomore year for classes that would be continuing.

In spite of her challenges, Maggie was quite self-assured and not particularly upset by her difficulties. After all, this was not Maggie’s first go-round. She had two prior concussions, and her second one, in seventh grade, resulted in a similar, more debilitating long-term memory impairment. After that injury, Maggie fully regained her memory function after five months, and returned to her previous level of functioning. Maggie was confident that this, too, would be a temporary struggle.

After three sessions with me, Maggie felt more adjusted at school and found her memory was gradually improving. By her last visit, she could verbalize and demonstrate strategies to cope with her memory difficulties: She had met her treatment goals. As with any new challenge we face in our recovery journey, I likely learned more from Maggie than she did from me. I learned that our role as clinicians is to tailor our treatment to the person in front of us, even if what we see is completely unanticipated.

Maggie and I focused her treatment on strategies for managing the mental blanks she faced when trying to access pre-concussion information.

In her own words

Maggie is now thriving in her junior year of high school. She spoke with me about her perspective on managing long-term memory loss while taking on the rigors of high school academics.

Q How are you feeling in terms of your recovery from last summer’s concussion?

I’d say I’m 100 percent. I’m back to doing all my normal activities at the same level as before my concussion and not experiencing any symptoms.

Q Describe your symptoms following your concussions.

I initially had a concussion in spring of fifth grade but it wasn’t too bad, and I didn’t have any memory issues with that one. However, with both my second (seventh grade) and third (summer before 11th grade) concussions I felt pretty foggy, and my head really hurt immediately following the impacts. The memory loss then started within 24 hours each time.

Over time, the headaches and mental fogginess continued, and the memory loss became more prevalent. My second concussion was a longer recovery than my third. With my second, symptoms lasted about five months, whereas in my third concussion they subsided in about three months.

Q What do you remember about your visit to our concussion clinic?

Following my third concussion, I was able to get into the clinic quickly because of my connection with one of the Stanford pediatricians who was concerned about its severity. When I got to the clinic, they made me go through some tests with a physical therapist; those were primarily motor tests to see how my physical condition changed as we did different exercises. Then I visited the speech-language pathologist, Chris, and we did more mental testing, like short- and long-term memory tests.

We took a proactive approach to researching a place or topic before Maggie needed the information.

Q What strategies did you learn to help with your memory?

With my second concussion I downloaded an app [we used “FaceCards” and “Name Shark”] that allowed me to store people’s faces, along with their names, and that was very helpful for me. I would also try to be upfront with the people I didn’t remember about my memory loss. I would let them know what they could do to help or remind me.

For both of my bigger concussions, one of my biggest strategies—mostly if it was a situation where I didn’t want to have to explain my memory loss—was to pick up on cues in what a person was saying. I would try to answer using those cues and give what I thought would be the most appropriate generic answer.

Q You handled your memory impairment very well. What did it feel like to not be able to remember your past?

It’s really strange to not be able to remember your past and especially the people in it. Certain events and people felt very familiar to me, yet details were foggy. For others, it was like it never happened. It’s really strange to have people telling you about things you’ve done and yet not be able to remember any of it. I was just living in the present at that point because I didn’t really remember a lot about my past.

Q What did you do to prepare for the first week of school?

Preparing for school with my most recent concussion was pretty difficult. I had summer assignments for some of the AP classes I was taking—notes for biology and reading for English—and didn’t have to have any previous knowledge to complete them, so my long-term memory loss wasn’t a problem.

However, I continued to have headaches. I couldn’t really read without experiencing a flare in my symptoms, so I had to postpone most of my summer assignments until later because I couldn’t do them prior to school starting.

Q What did you find most helpful in treatment?

With the physical therapy, most helpful were the focusing exercises. I would have to stare at a specific point and turn my head from side to side to the beat of a metronome, while still keeping my eyes trained on that point. That helped me a lot with my focus and trying to be able to ignore background distractions to focus on one thing—something I was struggling with during my concussion. In terms of mental therapy, it helped me to have exercises and pathways to follow to see if I could remember things.

In the [cognitive and memory treatment], my primary concern wasn’t forcing my memories to return because I knew from prior experience that they would, but it was important for me to have strategies to cope in the moment. For example, Chris and I created this pathway system for figuring out someone’s name. Sometimes even with the people I didn’t remember, I would have an inkling about the structure of their name or what it started with. I was supposed to use that idea to come up with common names I knew that fit that description and go through them mentally to see if any of them seemed familiar. This didn’t always work, but it was one of the strategies that was most effective in eliciting memories.

Q How were your first few months of school following your concussion? How is it going now?

The first few months of school were all right in some aspects and pretty rough in others. In many of my classes, we were learning new material, so my memory impairment wasn’t really a problem because I didn’t have issues retaining new information. However, I continued to have issues with other symptoms, such as headaches during long periods of concentration, like essays or tests. It worked out, though, because my guidance counselor and teachers were supportive of my recovery and of me modifying schoolwork temporarily or taking breaks if it came to that point.

Now that I’m feeling 100-percent back to normal, school is great. It’s everything you would expect being a high school junior. It can get hard and stressful at some points, but you just need to persevere. That’s the norm for any kid my age, so no concussion-related issues are currently affecting my school life.

Q What would you want other students like you to know if they experience a concussion?

That your concussion is most likely going to just be a temporary facet of your life. Even if in those moments you are frustrated and are facing certain symptoms, you’ll get past them and be able to return to your normal routine. Also, the doctors and people you visit to diagnose and help you with your recovery just want to help, so try not to get too frustrated. They’ve most likely seen many cases like yours and are relaying strategies and hints to you to help you recover as quickly as possible.